Ultrasound in primary care: Consensus recommendations on its applications and training. Results of a 3-round Delphi study

Abstract Background The introduction of portable and pocket ultrasound scanners has potentiated the use of ultrasound in primary care, whose many applications have been studied, analyzed and collected in the literature. However, its use is heterogeneous in Europe and there is a lack of guidelines on the necessary training and skills. Objectives To identify the fundamental applications and indications of ultrasound for family physicians, the necessary knowledge and skills, and the definition of a framework of academic and pragmatic training for the development of these competencies. Methods A modified 3-round Delphi study was carried out in Catalonia, with the participation of 65 family physicians experts in ultrasound. The study was carried out over six months (from September 2020 to February 2021). The indications of ultrasound for family physicians were agreed (the > = 75th percentile was considered) and prioritised, as was the necessary training plan. Results The ultrasound applications in primary care were classified into seven main categories. For each application, the main indications (according to reason for consultation) in primary care were specified. A progressive training plan was developed, characterised by five levels of competence: A (principles of ultrasound and management of ultrasound scanners); B (basic normal ultrasound anatomy); C (advanced normal ultrasound anatomy); D (pathologic ultrasound, description of pathological images and diagnostic orientation); E (practical skills under conditions of routine clinical practice). Conclusion Training family physicians in ultrasound may consider seven main applications and indications. The proposed training plan establishes five different levels of competencies until skill in real clinical practice is achieved.


Introduction
The development in recent decades of portable and pocket ultrasound scanners has allowed the point-ofcare application of ultrasound, both in physicians' offices and in the home [1], making it an accessible tool for family physicians.
A systematic review of the applications of point-ofcare ultrasound in primary care, published in January 2019 [2], concluded that the precision with which family physicians perform ultrasounds was good in quality studies but also emphasised the importance of training and the disparity of criteria on this point, with wide variations in the duration and type of training received.
There are wide variations in the use of point-of-care ultrasound between European countries [3]. The expansion and introduction of ultrasound into the regular practice of family physicians is already a reality in some European countries while in others, it is still a project in development or an isolated, one-off event.
The ultrasound performed by the family physician should be contextualised in a clinical setting, accompanied by a history and physical examination, and often aimed at answering a specific clinical question [4]. Given the broad spectrum of competencies and tasks performed by family physicians, the ultrasound applications are multiple and varied. Its claimed benefits are limited not only to completing a diagnosis but may also allow risk stratification, ruling out other diagnoses or associated complications, guiding therapeutic decisions, monitoring the response to treatment, serving as a guide for punctures, and screening for some diseases [5].
At the same time, the provision of ultrasound scanners in primary care should be accompanied by thorough, accredited training of professionals. Some specialty programmes include the training of the resident family physician in ultrasound-related competencies, especially in U.S. teaching units [6,7]. However, ultrasound training should be available not only for residents but also for senior specialists. Training may lead to a change in clinical practice and a more remarkable ability to solve ongoing health problems [8].
This study aimed to identify the fundamental applications of ultrasound for family physicians, the necessary knowledge and skills, and the definition of a framework of academic and pragmatic training for developing these competencies.

Methods
This study was conducted in Catalonia, Spain from September 2020 to February 2021. A literature review was carried out, and the ultrasound applications in primary care were listed [2,4]. Through a modified (includes a joint committee between first and second rounds) 3-round Delphi study, the indications of ultrasound for the family physician and the training plan were agreed and prioritised. All family physicians participating in the Delphi study were members of the ultrasound group of Catalan Society of Family and Community Medicine. Procedure and rounds: Between the first and second rounds, results were discussed in a joint committee composed of six family physicians and six radiologists. Figure 1 shows the diagram followed in the process.
For the development of the training plan, international recommendations from various specialties on the evaluation of competencies in ultrasound [9] were taken into consideration. The competencies agreed in the Delphi study were: (1) indication of ultrasound, (2) knowledge of the ultrasound scanners, (3) image optimisation, (4) systematic examination, (5) image interpretation, (6) ultrasound recording and documentation, and (7) clinical decision making. According to these competencies, a training plan was designed by seeking consensus on the number of hours needed to acquire these skills on each of the applications. It should be considered that these are the minimum hours necessary to establish the learner's autonomy and continuous training and consulting programmes that guarantee the quality and safety of the patient are required. When the minimum training hours are completed, an exam may accredit the corresponding level of competence.
The results of the Delphi study were analysed with descriptive statistics using the R program version 3.6.1 for Windows. In each round, the 75th percentile was considered to assess consensus.

Applications
The Delphi study identified seven main ultrasound applications in primary care (Table 1). For each application, different structures to be evaluated raised consensus (Table 1). Table 2 shows the agreed main indications of ultrasound in primary care according to reason for consultation. The indications also contemplated the ultrasound use to guide different procedures.

Training plan
The Delphi study established five levels of competencies (from A to E), and described the expected skills at each level. Table 3 shows the fundamental structure of the training plan, which is progressive. To accede to each level of competence, the previous levels must have been accredited.
The minimum number of hours required to accredit the training is shown in Table 4.

Main findings
This document includes the consensus recommendations of the ultrasound group of the Catalan Society of Family   Abdomen: includes liver, gallbladder and bile ducts, spleen, pancreas, large abdominal vessels, kidneys, bladder, gynaecological/obstetric, prostate and scrotal study Neck: includes thyroid and parathyroid, major salivary glands (submaxillary and parotid), upper airway, vascular bundles and cervical ganglion chains Musculoskeletal: includes joint, tendon, muscle and bursa assessment, specific for one of the main joints in primary care: shoulder, elbow, wrist, hip, knee, ankle Soft parts: dermis and epidermis, subcutaneous fatty tissue Cardiac: evaluation of heart rate, significant dilation of cavities, global contractility, ejection fraction, pericardial effusion, detection of severe valve disease Thorax: includes chest wall, pleural pathology (pneumothorax, pleural effusion … ), pulmonary pathology with interstitial or alveolar (peripheral) involvement and diaphragmatic assessment Vascular: includes large vessels, supra-aortic trunks, limb veins … Applications of ultrasound that were approved by consensus after the 3 rounds ('Procedures with ultrasound') was accepted by consensus.
and Community Medicine, on the use of ultrasound in all areas of care of family physicians. This Delphi study establishes a framework of applications and skills and a training plan, which may serve as a guide for training programmes in ultrasound in primary care.

Applications
The list of ultrasound applications in primary care may be widely extended. A 2019 Danish study described two main approaches to ultrasound for the family physician; focused clinical ultrasound (aimed at a specific question) or exploratory examination, in a wide range of applications [26]. In a 2020 Danish study, a group of local experts prioritized 30 very varied examinations [27], ranging from determining bladder volume to trochanteric bursitis. However, most ultrasound examinations performed in primary care are abdominal, and this is where more family physicians have received ultrasound training [28], followed by musculoskeletal and head and neck ultrasound. In our document, seven areas of knowledge were defined, as well as using ultrasound for guiding procedures.

Training plan
For the training plan, although levels of competence are typical for any ultrasound, the hours of training required vary according to the different applications.
To the accreditation of competencies, the agreed document for assessing of skills in point-of-care ultrasound can be used as a guide [29]. Levels A and B accredit knowledge, level D both accredits knowledge and assesses the skill needed, while levels C and E specifically accredit skills. Level E requires tutored practice in a clinical environment with real patients. For this, the learner must be supervised in carrying out ultrasound examinations by a tutor with accredited experience in ultrasound, until a pre-established number of scans are reached, with an index of agreement with the tutor of >0.7 [30]. We recommend that the tutor is a family physician and that practice is carried out in real clinical conditions. Training for the most advanced level, which involves real clinical practice, may differ. In some cases, the ideal training   environment for some ultrasound skills may be the hospital. At this level of advanced skills, collaboration with other specialities is vital.

Strengths and limitations
The availability of ultrasound in primary care varies widely in Europe. Current scientific evidence and technological progress makes its dissemination advisable requiring an implementation plan that includes a structured and accredited training plan, which guarantees its safe use. In Catalonia, the recent provision of ultrasound scanners in most primary care centres, involved developing a training plan for family physicians. Even though this plan has been developed by consensus of family physicians with expertise in ultrasound, the tremendous territorial variety makes it difficult to establish a common strategy for the implementation of ultrasound in primary care. The different European countries start from very remote situations requiring a specific individualised approach.

Implications
Ultrasound training for family physicians should cover clinical knowledge, practical skills in using ultrasound scanners and various learning and practice options, both through live tutoring and with consults at a distance with radiology services. In addition to the knowledge and skills of the technique itself, physicians performing ultrasounds must know the physical principles and operation of ultrasounds and their clinical indications, as well as have the ability to record images and videos in the medical record, write an ultrasound report and make clinical decisions using the information obtained. The creation of referral and consulting circuits that provide communication channels with other related specialities and especially radiology, is highly recommended.
Training family physicians should be accompanied by a national strategic plan for implementing ultrasound. It is necessary to consider not only the benefits but also the risks of introducting ultrasound in primary care and establish a quality training system.

Conclusion
Training family physicians in ultrasound may consider seven main applications and indications. The proposed training plan establishes five different levels of competencies until skill in real clinical practice is achieved.